Provider Demographics
NPI:1649276502
Name:MINNICK, KATHERINE A (MD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:A
Last Name:MINNICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:1481 TOBIAS GADSON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4879
Practice Address - Country:US
Practice Address - Phone:843-402-3093
Practice Address - Fax:843-402-3094
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC19855207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT38938Medicaid
SCT38938Medicaid